Communities ‘must be prepared to accept’ MDA interventions

To mark the publication of new research on mass drug administration to eliminate lymphatic filariasis, the director of India’s National Vector Borne Disease Control Program, Dr. Neeraj Dhingra, explains how he and his team addressed community fears, and highlights the power of partnerships

A young woman takes part in a mass drug administration campaign in Maharashtra, India.
©Monica Charmode Raghorte

Lymphatic filariasis, more commonly known as elephantiasis, is a chronic disease that can cause severe disfigurement. It also makes life very difficult for those who contract it – and often takes a devastating emotional toll.

New research has found that the most effective way to combat the neglected tropical disease – spread by infected mosquitoes that deposit a parasite that travels to and obstructs the lymph system – is yearly mass drug administration (MDA).

Exemplars in Global Health will soon publish its findings, aiming to help accelerate India’s progress in eliminating lymphatic filariasis, by documenting the best practices of high-performing states such as Maharashtra, which has a highly endemic population. Overall, India bears 50 percent of the global disease burden of the disease and has ambitious plans to eliminate it by 2021 through MDA.

Ahead of the publication of this research, we spoke with Dr. Neeraj Dhingra, the Director of India’s National Vector Borne Disease Control Program.

Exemplars News: Could you give us an overview of the campaign to eliminate lymphatic filariasis (LF) in India?

Dr. Neeraj Dhingra: India has the highest morbidity due to the LF in the world. There are around 650 million people who are living in LF-endemic areas in India. LF causes disfigurement and leads to handicaps and long-term disabilities. India follows a two-pronged strategy for LF. First, mass administration of drugs for filaria and, second, morbidity management and disability prevention. Since the program’s inception in 2004, two drugs, diethylcarbamazine and albendazole, have been administered. MDA is done once a day annually and the purpose of these drugs is to eliminate parasitic infection. If administered for five to six years consecutively, with good coverage and compliance, it is expected that the parasite will be eliminated and transmission will be interrupted. As of now, 98 of the country’s total 272 districts have been able to reach that level of elimination. In 2018, under the Accelerated Plan of Action for Elimination of LF, India adopted Triple Dug Therapy called IDA and included Ivermectin in the regime. We started with five pilot districts for Triple Drug Therapy and so far, at least 31 districts have conducted at least one round of IDA. It’s expected that the use of these three drugs will cut the time required for interruption of transmission from five years to 2-3 years.

Exemplars News: How did you address community fears and drive increased acceptance and awareness of MDA?

Dr. Neeraj Dhingra: One month before the MDA, there is a district task force meeting. In these meetings all stakeholders and government departments at the district level are represented, like the Panchayati Raj [village councils], women and child development, etc. Various stakeholders are informed about the roles they can play in the MDA campaign, [and] advocacy and mass media campaigns to involve and inform the population of the MDA dates are undertaken. Local community leaders, the electorate representatives of these areas, local opinion leaders, are also involved. The campaigns include print media, folk troupe performances, etc., to make the population aware. Other important influencers are Anganwadis (a cadre that takes on child nutrition and health care tasks in rural settings) and the religious leaders, who play a very important role in community mobilization. We inform people that the side effects are minimal and promote compliance of the drugs. On the day of the MDA, or a day before, campaigns are launched by eminent religious leaders, or political leaders, or some popular actors. They demonstrate drug consumption before the community. This is widely publicized in local newspapers and the TVs, and now, social media. We undertake all these measures, so that community is aware, and [to] allay fears of side effects.

Exemplars News: How important are partnerships in bolstering efforts to improving LF elimination efforts in India?

Dr. Neeraj Dhingra: MDA is a huge exercise covering more than 600 million people in the country. Public health systems have their own strengths in reaching a large population base, but areas like advocacy and behavior change are strengths of other agencies and partners. Therefore, a collaborative approach works best whereby the strengths of each are leveraged to reach the common desired goal. We involve various government departments like the Woman and Child Development Department, the Panchayati Raj institutions, the Education Department, etc. We also have partnerships with various research institutions, like the Indian Council of Medical Research. We engage with politicians, bureaucrats and government, and multiple organizations supported by the WHO and the Bill & Melinda Gates Foundation to achieve the end result.

Exemplars News: How do you think this Exemplars study can be used by other Indian states or countries?

Dr. Neeraj Dhingra: India is a very large country, we have 36 states and union territories, but every state’s federal structure has its own methodology of doing field operations. The National Program has standard operating procedures, but the states adapt them to local contexts so that they reach out to the maximum population and ensure a high rate of coverage and compliance. This Exemplar study will try to establish the best practices by a subset of districts that have eliminated LF. These practices can be replicated in other districts and other parts of the country. With this Exemplar study, we will be able to identify the reasons and develop models which can be offered to other states. We can give them examples of what worked the best in these areas. What are the issues in the states which have not achieved this result? That will help them learn because it will be information coming right from the ground. In my opinion, the most important thing in this Exemplar study is what motivates the local field staff and the acceptance of the community of the drugs.

Exemplars News: What advice would you give other health leaders who want to implement this type of program?

Dr. Neeraj Dhingra: With MDA, communities are often apprehensive because of the number of tablets administered – up to eight tablets for an adult. The political leadership, the technical leadership, and the researchers all have to allay fears about the drugs and their side effects and show that the intervention is safe and will prevent morbidity. The community must be, thus, prepared to accept this intervention. Second is meticulous planning since these are large-scale campaigns. This can be achieved through rigorous micro-planning. That means states, districts and facilities have to plan everything in detail. Pre-MDA activities prior to administration of the drugs are critical and should be undertaken in a very meticulous manner and [must] follow timelines. If pockets of resistance are encountered anywhere during the pre-MDA phase, these should be addressed through appropriate behavior change strategies.

Exemplars News: Is there anything you wish you could have done differently or better?

Dr. Neeraj Dhingra: The main challenge we face in India is community and social mobilization, for which we need more involvement of the non-governmental organizations. We need more involvement of civil society organizations. As this is a mass campaign, reaching the last mile will not happen unless and until the non-governmental partners are engaged. They have been trying, and I think this is one sector which we need to engage and utilize more and better. Also, we need more funding for filariasis since it’s a neglected tropical disease, and the available funding is much less compared to other diseases like HIV or TB. Another aspect that needs to be strengthened is morbidity management since lymphatic filariasis is a chronic disease and results in the need for long-term care. There is no cure for filariasis once elephantiasis and lymphedema develop – such cases need to be provided long-term support.